Prior Authorization

Insurers’ progress on fixing prior authorization is disappointingly slow

Andis Robeznieks , Senior News Writer

A year ago, health insurance trade organizations agreed on the need for plans to reduce unnecessary burdens and promote timely access to care by revising their prior authorization (PA) processes to be more data-driven and transparent, but new physician survey results show that insurers have not widely implemented these changes and the process has instead become more burdensome and time consuming than ever.

“Physicians follow required insurance protocols for prior authorization that involve recurring paperwork, multiple phone calls and hours spent on hold,” said AMA President Barbara L. McAneny, MD. “At the same time, patients’ lives can hang in the balance until health plans decide if needed care will qualify for insurance coverage.”

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Physicians are reporting an increase in PA volume that includes requirements for drugs and services that are neither new nor costly. This includes long-available generic drugs and prescriptions for patients on an established medication regimen to manage a chronic condition.

The AMA has worked across several fronts to reform PA, including producing videos on how PA harms patients and burdens physicians, advocating with state legislatures and collaborating with health plans.

The AMA worked with payer trade organizations America’s Health Insurance Plans (AHIP) and Blue Cross Blue Shield Association (BCBSA) and national associations representing hospitals, pharmacists and medical groups to develop a PA reform consensus statement that was released in January 2018.

The statement identified five opportunities to right-size PA, and it included agreements to take specific actions on each of them. But little to no progress has been made and, in some areas, the situation is getting worse, according to 1,000 practicing physicians surveyed in December 2018.

Under the consensus statement, AHIP and BCBSA agreed to encourage their member health plans to:

Selectively apply PA and exclude physicians who have high rates of PA approval, prescribe according to evidence-based guidelines or participate in risk-based payment contractual agreements. Yet only eight percent of physicians surveyed reported contracting with health plans that offer programs exempting them from PA.

Adjust the volume of PA requirements to reflect drugs and services with low variation in utilization or low PA denial ratesHowever, instead of experiencing a reduction in the number of drugs requiring PA, 88 percent of physicians said the number has gone up. Similarly, 86 percent of physicians reported that the number of services requiring PA has gone up, too.

Improve transparency and clearly articulate PA criteria, rationale and program changesBut 69 percent of physicians reported it was difficult to determine which medications or services required PA.

Protect continuity of patient care by ensuring continued access to effective treatment during health plan or coverage changes and eliminating repetitive PA requirements. Surveyed physicians indicated that this is not happening, as 85 percent report that PA interferes with continuity of care.

Accelerate use of automation in PA processing. Despite health plan commitment to utilization of standard electronic transactions for PA, physicians report that phone and fax are still the most common methods for completing PAs. Additionally, only 21 percent of physicians report that their electronic health record system offers electronic PA for prescription medications, despite an existing standard process.

A rare example of progress involves removing delays in treating opioid-use disorder (OUD). In Pennsylvania, for example, insurance companies agreed to remove PA requirements for medication-assisted treatment to help people with OUD. Bills mandating similar action have been introduced in the Kentucky and Vermont legislatures. The AMA is working to get other states to remove PA barriers to treatment.

“There is no reason for insurers to use prior authorization for medications to treat opioid-use disorders when patients’ lives hang in the balance,” said Dr. McAneny.

Larger PA reform legislation is also being considered by state legislatures this year. States such as Kentucky, Colorado, Maine and Virginia are among those with bills to reduce delays in care as a result of PA and to increase the transparency of PA programs.

The AMA has also advocated extensively with federal regulators to oppose increased use of PA and other utilization management programs in Medicare programs.  In September 2018, the AMA and over 90 other state medical associations and national medical specialty societies wrote the Centers for Medicare and Medicaid Services (CMS) objecting to a policy change that permits the use of step therapy for drugs covered under Part B in Medicare Advantage (MA) plans.  The AMA also submitted comments objecting to a planned expansion of PA and step therapy use in Medicare Part D and Medicare Advantage plans. Finally, the AMA recently partnered with state and specialty medical organization in a sign-on letter urging CMS to provide strong guidance on use of PA in MA plans in its 2020 Call Letter.

The AMA invites patients to share their experiences with PA and to sign a petition urging reform at